Chapter 15Vital Signs

15:1 Measuring and RecordingVital Signs (VS)• Record information about the basic body conditions• Main vital signs (VS)• Temperature• Pulse• Respiration• Blood pressure

Other Assessments• Pain—patients asked to rate on scale of

1 to 10 (1 is minimal and 10 is severe)• Color of skin• Size of pupils and reaction to light• Level of consciousness• Response to stimuli

VS Readings• Accuracy is essential• Report abnormality or change • If unable to get reading, ask another

person to check

Measuring and Recording Temperature • Measures balance between heat lost and heat produced in the

body• Heat produced by metabolism of food and

by muscle and gland activity• Homeostasis: constant state of balance in

the body• Conversion between Fahrenheit and Celsius temperature

Variations in Body Temperature• Normal range• Causes of variations• Temperature measurements—oral, rectal (often used on

infants/children), axillary or groin, aural, and temporal

• Abnormal conditions affecting temperature

Thermometers • Clinical thermometers• Glass• Electronic• Tympanic• Temporal• Plastic or paper

• Reading thermometers and recording results

Thermometers

• Avoid factors that could alter or change temperature• Cleaning thermometers• Paper/plastic sheath on glass thermometer

Measuring and Recording Pulse• Pulse: Pressure of the blood pushing against the

wall of an artery as the heart beats and rests• Major arterial or pulse sites:• Temporal, carotid, brachial, radial, femoral, popliteal & dorsalis

pedis• Pulse rate• Adult men- 60-70 bpm• Adult women- 65-80 bpm• Children over 7yrs- 90 bpm• Children 1-7yrs- 80-110 bpm• Infants- 100-160 bpm

• Pulse rhythm- regularity of beat• Pulse volume- strength or intensity of pulse

Measuring and Recording Pulse • Arrhythmia- irregular or abnormal rhythm, usually caused by a defect in

the electrical conduction pattern of the heart

• Factors that change pulse rate:• exercise• Stimulant or depressant drugs• Excitement• Fever• Shock• Nervous tension• Sleep• Depression• Heart disease• Coma

• Basic principles for taking radial pulse• Recording information

Measuring and Recording Respirations

• Measures the breathing of a patient• Respiration: Process of taking in oxygen and expelling carbon

dioxide from the lungs and respiratory tract• One respiration: one inspiration (breathing in) and one expiration

(breathing out)

Measuring and Recording Respirations • Normal respiratory rate:• Adults: 14-18 breaths per minute• Children: 16-25 breaths per minute• Infants: 30-50 breaths per minute

• Character of respirations- the depth and quality of respiration• Rhythm of respirations- regularity of respirations• Abnormal respirations:• Dyspnea- difficult or labored breathing• Apnea- absence or respirations, usually temporary• Tachypnea- respiratory rate above 25 respirations per minute• Bradypnea- slow rate, usually below 10 respirations per minute• Orthopnea- severe dyspnea in any position other than sitting erect• Cheyne-Stokes- periods of dyspnea followed by apnea (often in the dying)• Rales- bubbling or noisy sounds caused by fluids or mucus• Wheezing- difficult breathing with whistling • Cyanosis- dusky, bluish discoloration of the skin, lips and nail beds

• Voluntary control of respirations• Record information

Graphing TPR• Graphic sheets are special records used for recording TPR• Presents a visual diagram• Uses: most often in hospitals and long-term care facilities• Color codes: EX: temperature in blue ink, pulse in red ink and

inspirations in green ink• Factors affecting VS are often noted on the graph: surgery,

medications and antibiotics

(continues)

Graphing TPR

• Graphic charts are legal records: must be legible, neat and accurate

• To correct an error- cross out error with red ink and initialed

Measuring and Recording Apical Pulse

• Apical Pulse- count taken at the apex of the heart with a stethoscope

• Reasons for taking an apical pulse: patients with irregular heartbeats, hardening of the arteries, or weak or rapid radial pulse

• Protect the patient’s privacy and avoid exposure• Heart sounds: lubb-dubb; sounds of the heart valves opening and

closing in the heart• Abnormal sounds or beats

(continues)

Measuring and Recording Apical Pulse

• Pulse deficit: check the apical pulse while a second person checks the radial pulse; subtract the radial pulse from apical pulse for difference

• Use the stethoscope• Placement of stethoscope: 2-3” to left of breastbone• Measuring apical pulse• Record all information

Measuring and Recording Blood Pressure

• Blood Pressure- Measurement of the pressure the blood exerts on the walls of the arteries during the various stages of heart activity

• Measured in millimeters of mercury on a sphygmomanometer• 120/80 mm Hg

• Measurements read at two points:• Systolic pressure- occurs in the walls of the arteries when the left

ventricle of the heart is contracting and pushing blood in the arteries• Diastolic pressure- the constant pressure in the walls of the arteries

when the left ventricle of the heart is at rest, or between contractions

(continues)

Measuring and Recording Blood Pressure

• Pulse pressure: the difference between systolic and diastolic pressure

• Hypertension—high blood pressure; >140/90• Hypotension—low blood pressure; < 100/60• Factors influencing blood pressure readings (high or low):• Force of the heartbeat• Resistance of the arterial system• Elasticity of the arteries• Volume of the blood in arteries• Excitement, anxiety, nervous tension, shock• Stimulant and depressant drugs• Exercise and eating or fasting• Rest or sleep• Lying down, standing up or sitting position

Measuring and Recording Blood Pressure

• Individual factors can all influence blood pressure readings• Types of sphygmomanometers• Mercury• Aneroid- no mercury but calibrated in mmHg• Electronic

Measuring and Recording Blood Pressure• Factors to follow for accurate readings: size and placement of

sphygmomanometer• Record all required information• Do not discuss the reading with the patient; it’s the doctor’s

responsibility

Summary• Vital signs are major indicators of

body function• Accuracy of measurement and recording

of vital signs• The health care worker needs to be alert

and report any abnormalities